Recently, AdvanceMed identified, in performing both post pay medical reviews and data analysis
regarding trends in utilization, that the Q5 modifier is being used and/or billed incorrectly. It appears that the misunderstanding of the modifier’s function and/or the failure to provide the required supporting documentation have resulted in many of these errors. When used appropriately, the Q5 modifier is utilized for payment of physician claims submitted under Reciprocal Billing Arrangements. According to the Code of Federal Regulation, Social Security Act, the Centers for Medicare & Medicaid Services, and the Medical Claims Processing Manual, it is the provider’s responsibility to document any service provided. When the Q5 modifier is used, this documentation must include the reason for using the modifier.
When a provider utilizes the Q5 modifier, they must understand the following:
• The regular physician is unavailable to provide the service(s) to be rendered;
• The Medicare beneficiary has arranged, or seeks, to receive services from the regular physician;
• The substitute physician does not provide the services to Medicare beneficiaries over a continuous period of more than 60 days, and
• The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering in item 24d of Form CMS-1500 HCPCS code Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by entering the unique physician identification number (UPIN) or NPI when required on the form and cross-referring the entry to the appropriate service line item(s) by number(s). Until further notice, the regular physician must keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s UPIN or NPI when required, and make this record available to the carrier upon request.
It should be emphasized that the use of the Q5 modifier is allowed only when the regular physician is unavailable.
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